Psychedelic drugs, hippie counterculture, speed and phenobarbital treatment of sedative-hypnotic dependence: a journey to the Haight Ashbury in the sixties.
During the sixties, thousands of people migrated to the San Francisco Bay Area, settling in the North Beach District, Berkeley, or the Haight-Ashbury. Some were writers, like Allen Ginsberg and the beat poets, others artists and musicians. Some were seeking a spiritual alternative to Catholicism, Judaism, or the protestant religions of their parents. Influenced by books such as The Psychedelic Experience (Leary, Metzner & Alpert 1964) and Huxley's (1954) Doors of Perception, they blended Eastern mysticism, Native American rituals and psychedelic drug use into what would variously be called the "hippie movement" or the "psychedelic drug counterculture."
Most hippies opposed the Vietnam war and the military draft, competitive materialism, and drug laws--particularly those prohibiting marijuana and psychedelics. Some embraced self-imposed poverty. They were seeking a lifestyle different from the mainstream culture, one that deemphasized consumerism and military imperialism, one that was in principle communal but also remained in some ways staunchly individualistic that would allow everyone to "do their own thing."
The hippies were anti-science. They did not oppose the putative facts of science, its suppositions or theories on religious grounds like the medieval church or modern creationists; they objected to science as a tool of the military industrial complex. A "smart bomb" would be an oxymoron.
Psychedelic drugs, an important component of the counterculture, were used in a variety of ways: recreation, self-exploration, or as a method of achieving transcendental experiences. Some thought psychedelic drugs provided a path to spiritual enlightenment. The use of psychedelics and the then recently-introduced birth control pills supported their ubiquitous motto of "better living through chemistry." Dancing and music, especially by the Grateful Dead, were also key elements of the counterculture. Inspired by Tom Wolfe's book, The Electric Kool-Aid Acid Test (1968), chronicling the adventures of Ken Kesey and his band of Merry Pranksters traveling across the country in 1964 in a brilliantly painted school bus. Volkswagen vans and decommissioned school buses became the signature hippie mode of travel. In venues such as the Fillmore Auditorium in San Francisco, they repeatedly "tested" their ability to withstand blasting music, strobe lights and vibrant flashing colored lights while under the influence of LSD. (These bacchanalian gatherings were the precursor of the Ecstasy-driven raves that followed years later.)
Hippies, while opposed to the Vietnam war, were not necessarily antiwar activists nor pacifist. The slogan "make love not war" and the circular peace symbol were ubiquitous within the hippie subculture, but for many, their primary objection was that they were subject to a draft and could be conscripted into military service by "the establishment."
On January 14, 1967 an event in San Francisco's Golden Gate Park decisively detoured the lives of everyone already living in the Haight-Ashbury and the thousands of migrants, many in their early teens, who would flock there. Yellow posters touted the event as a "Human Be-in," a "Gathering of the Tribes." Attendees were encouraged to bring flowers, incense, cymbals, their animals and their kids. Timothy Leary, Richard Alpert and Allen Ginsberg would speak and rock bands--Santana, the Steve Miller Band, and The Grateful Dead--would perform.
On an unusually warm January day, Leary delivered his "turn-on, tune-in and drop-out" speech. Thousands of followers wearing head-bands, tie-dyed T-shirts and way too much hair smoked pot, dropped acid and danced at the Polo Field in Golden Gate Park. The event's organizers intended to bring together the divergent and sometimes fractious "tribes": activists promoting civil rights, those opposing the Vietnam war, and urban and rural hippies. The Be-in was highly publicized in the underground press, and in some ways, a tragic success. Hippies were further popularized in the mainstream press as rebellious youth, dismissive of authority, anti-Vietnam activists, psychedelically crazed, and advocates of free love and rock and roll. The Haight Ashbury was both deplored and rhapsodized over (see Editors of Time 1967a). The Be-in organizers and San Francisco city officials expected an influx of young people during the summer from around the country. The following summer tens of thousands of young people from all over the country migrated to the Haight-Ashbury District and the larger Bay Area for what would be called the "Summer of Love." They joined the already present artists, musicians, students, writers and poets, regular working-class families and hard-core drug users (e.g., heroin, methamphetamine and barbiturates) already living in the Haight-Ashbury. Many residents of the Haight Ashbury were already living in crowded communal or cooperative arrangements, and the area did not have adequate housing or medical resources to accommodate the influx of thousands of new young people.
Youth flocked to San Francisco to be part of the hippie scene, to dance, to listen to rock and roll, to protest the Vietnam war, and to take drugs, particularly marijuana, hashish, and psychedelic drugs. After they arrived, they took whatever drugs were popular or available: LSD (lysergic acid diethylamide), both real and bogus, psilocybin--"magic mushrooms" that were more often than not grocery-store mushrooms laced with LSD--and the latest creations of several world-class psychedelic chemists in the San Francisco Bay Area. Hippies were featured on the cover of Time magazine on July 7, 1967 (Editors of Time 1967b). The lead article was an unusually well grounded piece for the mass media of the time, placing the hippies and the Haight Ashbury into social, political and historical contexts. Although enclaves of hippies existed in New York; Boston; Seattle; Austin, Texas and other US cities, San Francisco was the epicenter and hippies were the media darlings. Department stores and boutiques sold "psychedelic" influenced artwork, tie-dyed T-shirts, bellbottom trousers and the vinyl records of acid rock bands such as the Jefferson Airplane, Big Brother and the Holding Company, and the Doors.
By fall of 1967, amphetamines were displacing psychedelics as the primary drugs of abuse in the Haight-Ashbury. Amphetamine use itself was not new. Oral amphetamine tablets had been widely used during the 1950s for appetite suppression. The "beat" generation used prescription oral amphetamine (e.g., Dexedrine[R]) and methamphetamine (Desoxyn[R]), but some individuals injected a pharmaceutically manufactured preparation of injectable methamphetamine called Methadrine[R]. Methamphetamine was also extracted and injected from Benzedrine[R] nasal inhalers (1). But increasingly, methamphetamine was becoming available as an illicitly manufactured product called "crank," "speed," or "crystal."
Researchers in the Haight-Ashbury were uncertain about who comprised the new population of methamphetamine users. One theory was that large numbers of the resident hippies had emigrated and been replaced by new arrivals who were less idealistic and found the use of methamphetamine and hard drugs more acceptable (Shick, Smith & Meyers 1969). Widespread availability also played a role. Methamphetamine was marketed in great part by the Hell's Angels who followed a fundamental market principle: it's not necessary to sell people what they want, sell them what you have. Methamphetamine production required much less sophistication than LSD or other psychedelics and the precursors of methamphetamine were cheap and readily available.
The distribution system for psychedelic drugs and marijuana was different from that of methamphetamine. One group of drug dealers sold psychedelics, hashish, and marijuana; others sold crystal, crank, heroin or barbiturates.
Many of the migrants to the Haight Ashbury eventually returned home, to school or to colleges. But some stayed behind and became enmeshed in the drug-using subcultures. Various theories were advanced to explain why methamphetamine became the primary drug of abuse in the Haight Ashbury. One theory proposed that drug users found a preference for particular drugs that was largely dependent on preexisting personality or psychopathology (Hartman 1969); another that frequent use of psychedelics induced a disorganized thought pattern that was improved, at least subjectively, by methamphetamine. Certainly there were individuals whose drug use would fit either theory.
While oral use of methamphetamine either as a primary drug of abuse or as an adulterant in psychedelics was increasing, a much more malignant pattern of methamphetamine use was developing: high-dose, intravenous injection. High-dose intravenous injectors were not primarily interested in the fatigue reduction, wakefulness, or appetite suppression that could be provided by oral amphetamine; they were chasing an intense "rush" that occurred right after injection. They would inject methamphetamine one to ten times a day and continue injections until they were hallucinating and paranoid, sometimes going for days without sleep (Cline & Williams 1969). The speed run continued until the user was, for whatever reason, unable to obtain more methamphetamine. The increasingly prevalent use of methamphetamine greatly contributed to the decline of the Haight-Ashbury community. The aggressive and sometimes violent intravenous methamphetamine user was incompatible with the aspirations and lifestyle of the hippie subculture and many of the hippies left the Haight-Ashbury to form communes that were more congenial to their lifestyle and belief systems (Smith 1969a). Even in the drug-tolerant Haight-Ashbury, the high-dose, intravenous methamphetamine users, known as "speed freaks," were marginalized (Pittel & Hofer 1973; Smith 1969c).
In parallel with increasing use of methamphetamine, the use and abuse of short-acting barbiturates was also increasing; secobarbital (Seconal[R]), known by the street name of "reds," and pentobarbital (Nembutal[R]) or "yellows" were the preferred barbiturates. Researchers in the Haight-Ashbury would later expound that "downers" such as barbiturates and heroin were a predictable progression from methamphetamine because barbiturates and other sedative hypnotics were often used to terminate a "speed run" or to ameliorate the side effects of speed (Shick, Smith & Wesson 1973). Barbiturates taken orally or injected were also used as primary intoxicants, alone or in combination with heroin and as a heroin substitute when heroin was not available.
Unlike crank and speed, barbiturates and other prescription sedative-hypnotics were produced by pharmaceutical companies and reached the street-drug user in many ways, such as diversion by pharmacists, inappropriate prescribing, and diversion from pharmaceutical companies (Smith & Wesson 1973).
THE HAIGHT ASBURY FREE MEDICAL CLINIC (HAFC)
San Francisco's city officials and community leaders had rightly predicted that during the summer of 1967 a large migration of young people would further overwhelm the city's public health and medical resources. In response to the anticipated deluge of youth without access to medical care, Dr. David E. Smith founded the Haight-Ashbury Free Medical Clinic. The term "free clinic" had connotations beyond economic: open to all, free from judgment about life-style, and free from conventional mores. The medical staff was largely made up of volunteers. Patients lined up outside the door on opening day, June 7, 1967. Offices and exam rooms were on the second floor of an old Victorian on the corner of Haight and Clayton Street, a block west of the crossing of Haight and Ashbury. The clinic, staffed by volunteer doctors, nurses and support staff, would become a model for free clinics that developed across the nation. The beginnings of the Clinic are chronicled in Love Needs Care (Smith & Luce 1971), Dr. Dave (Sturges 1993), and The Haight Ashbury Free Medical Clinics: Still Free After All These Years (Seymour & Smith 1986). Many patients coming to the clinic were stoned on marijuana or some combination of other drugs. As part of the nonjudgmental ethos of the clinic, patients were not admonished for their drug use. The staff coped with or ignored patient's intoxication and focused on diagnosis and treatment of the presenting medical problem. Often penicillin or Flagyl (2) were sufficient. Medical problems that could not be treated at the clinic were referred to San Francisco General Hospital or one of the other scarce, and often inaccessible, public treatment facilities.
THE JOURNAL OF PSYCHEDELIC DRUGS
The first issue of the Journal of Psychedelic Drugs was published in 1967. Initially a mimeographed book, David Smith intended it as a means to rapidly disseminate accurate information to the medical and scientific community about the drugs used and the social-political context of their use in the Haight Ashbury. (In 1981, the name of the journal was changed to the Journal of Psychoactive Drugs to reflect the wider range of drugs covered, including prescription medications).
The hippie movement in the Haight-Ashbury was killed by TV and news media, commercial exploitation and methampthetamine. By emphasizing the "epidemic" use of psychedelics and the real, but most dramatic adverse consequences of LSD use, the media also promoted escalating drug control: penalties for sale and possession of drugs and the "war on drugs." Those who came to the Haight-Ashbury after January 1967 may have been less committed, perhaps less idealistic and more interested in having a good time than in establishing an alternative lifestyle. Whatever the reasons, the hippie movement was in decline. Nonetheless the hippie mode of dress, acid rock and posters became mainstream, and hippies became the objects of guided bus tours in their own neighborhood. Despite being able to cope with LSD, the hippies encounter with methamphetamine and barbiturates proved disastrous.
Psychedelics (LSD, mescaline, peyote, psilocybin) can produce profoundly altered states of consciousness and sensory perceptions, most commonly producing visual illusions (distortions of images), although visual hallucinations may occur. Under the influence of psychedelic drugs, a user may or may not realize the illusion or hallucination is drug-induced. The ability of a tiny amount of LSD to produce profound alteration of sense perception--visual, auditory and touch--is a vivid demonstration that what is perceived as external reality is not a fixed "out there" but a creation of the brain. In bright light, grass or trees appear green because receptors in the eyes, called cones, respond to certain frequencies of electromagnetic radiation. When these cones are stimulated and the resulting signal is transmitted first by the optic nerve and then neurons to the visual cortex and other parts of the brain, the brain creates an image that we have learned to call "green." In addition to color, the brain assigns additional attributes such as size and shape. Under the influence of LSD or other psychedelic drugs, shapes may be perceived as fluid.
LSD may also alter consciousness such that the boundaries between self and non-self seem to dissolve, a state that may evoke affects ranging from rapture to terror in different individuals. The changes in perception and consciousness are often associated with a sense that one is looking beyond ordinary perception and seeing things as they "really" are for the first time. Such effects lead some to the idea that psychedelic drugs were consciousness-enhancing, that they could be employed to enhance artistic creativity, or perhaps be a path to spiritual enlightenment, ideas influenced by Aldous Huxley's The Doors of Perception, which describes his experience with mescaline. Huxley's book, first published in 1954 (3), remains in print. He proposed that all mental events including mystical ones are neurochemically mediated, that mystics through the ages had induced changes in perception and consciousness by fasting, flagellation, meditation, starvation, or the ingestion of certain naturally occurring chemicals, such as mescaline. The idea that psychedelic drugs were a route to spiritual enlightenment was widely believed by psychedelic users, although it was later repudiated by some of its earlier adherents (e.g., Richard Alpert, an early proponent of LSD, who went to India and returned as Ram Dass) who advocated more traditional religious paths to personal spirituality.
Psychedelic drugs were more than a new class of extremely potent mind-altering drugs; they were symbols of the counterculture both in mainstream culture and within the counter-culture itself. In mainstream culture, psychedelic drugs users were widely dismissed as rebellious youth. Most psychedelic drug users saw themselves as alienated from mainstream culture, but unlike the antiwar protestors, they weren't trying to change mainstream culture. Most hippies wanted to be left alone to "do their own thing." That was not to be. They attracted a disproportionate amount of attention from mainstream media, law enforcement and legislators, and some took their experiences seriously. The first issue of the Journal of Psychedelic Drugs (Summer 1967) entitled "Psychedelic Drugs and the Law," consisted of papers presented at a June 24, 1967 University of California San Francisco conference, entitled "The Significance of the Psychedelic Experience."
FROM TAN COATS TO WHITE COATS
The afternoon of November 22, 1963, my freshman classmates and I were hunched over a formaldehyde-pickled cadaver in the anatomy lab at the University of Alabama Medical School in Birmingham. We were proud of our starched tan lab coats and our cadaver, a middle-aged African-American man. My classmates, 76 males and three females, were divided into groups of four or five, each assigned to a rectangular stainless-steel tank housing a cadaver. A mechanical arrangement at the head and foot of the tank lifted the body from its pungent liquid to support the body more or less at waist height for those of us standing around it. On that day, we were carefully dissecting muscles and fascia trying not to cut stringy branches of the brachial nerve in the left forearm. One of the teaching assistants called for our attention. He announced, in a tone that would have been appropriate to direct us to the nearest exit had the building been burning, that John Kennedy had been shot. In stunned disbelief, we wandered over to the windows and peered out as though the shooting had possibly taken place in the streets below.
In June 1968, I completed a general medical internship at Gorgas Hospital, a US-operated hospital in the Canal Zone of Panama. Although I had decided to do a psychiatry residency during my medical school training, I had not arranged for a psychiatry residency following internship. I was a member of the naval reserves and expected to go on active duty as a general medical officer immediately following my internship. To those of us raised during that era in the South, military service was taken as a fact of life, not a career or something you necessarily wanted to do, but something that had to be done. In any case, there was a draft, and physicians were included.
The military knew that medical specialists as well as general medical officers would be needed and a lottery system had been set up (4) to enable some physicians to complete residency training before beginning active duty. Near the end of my medical school training, I had applied for a deferment to compete a psychiatry residency and promptly forgot about it. During the later part of my internship, I received notice that I had been selected for a three-year deferment to complete a psychiatry residency; I needed to find a psychiatry residency program.
The San Francisco Oracle (5) was a newspaper published in the Haight Ashbury between 1966 and 1968. Much of the artwork was psychedelically inspired, and the articles and poetry by Allen Ginsberg, Gary Snyder, Lawrence Ferlinghetti and Michael McClure, were largely about psychedelic drugs, hippies and happenings in the Haight Ashbury. I decided that I would migrate to San Francisco after I completed my internship.
I applied to various psychiatry residency training programs near San Francisco, including the University of California Medical School program at Langley Porter. The residency matching program, done by computer using IBM punch cards, had already been completed for the upcoming academic year. Not surprisingly all psychiatric residency training programs in California were filled, except, it turned out, for one. The University of California Medical School had two psychiatry residency training programs: one at Langley Porter Psychiatric Hospital on the Parnassus campus of the San Francisco Medical Center; the other, a community mental health program at San Francisco General Hospital. Due to a computer glitch, the Community Mental Health Program, with four first-year psychiatry residency openings, had no matches.
One of the tenets of "community mental health" is that mental patients who posed no immediate threat to themselves or others would be better and more cost-effectively treated in their community instead of large state institutions. Treatment of patients in large psychiatric hospitals, it was argued, fostered dependence on the institution and did not provide patients the opportunity to practice skills they needed to return to their community. It was a reasonable theory, one that had considerable support among psychiatrists and more importantly, federal funding. The director of the community mental health program invited me to San Francisco for an interview, but I was unable to come. I had already used all my vacation time traveling in Panama and Costa Rica, but he was desperate, so he arranged an interview for me with a psychiatrist in the Canal Zone.
I began in June 1968, the only first-year resident. During the first three months I rotated to Napa State Hospital, a large California state mental hospital in the town of Napa about 30 miles north of San Francisco. One of the visiting lecturers there was Stanislav Grof (6), who talked about his experiences treating mental patients in Czechoslovakia with LSD. I was enthralled about the prospects of LSD as a therapeutic agent and the lure of LSD as a means of consciousness expansion. Fortunately, or unfortunately depending on your perspective, one of the neurology residents there shared my enthusiasm. He procured several doses of LSD that was supposedly pharmaceutically manufactured by Sandoz, a dose for him and one for me.
Although I had read many descriptions of LSD's effects in medical journals and the underground press and seen much LSD inspired artwork, I realized a few minutes into my first LSD trip that I had not understood much about it because the effects were qualitatively different from anything I had ever experienced. Objects that would otherwise be solid seemed fluid, vibrating, and intensely colored. Images, sometimes animated, emerged from clouds, wallpaper designs, and even the surface of colored light bulbs (lava lamps were popular at that time, oh yeah). Were the patterns really there, and I usually just didn't see them? Did other people see the same patterns? Was my experience of the color red the same as an artist? A new world opened and with it deep doubts about my ability to really understand anyone else's experience unless I had experienced something very similar.
Psychedelic users took them for many different reasons: self-exploration, a quest for consciousness expansion, curiosity, to escape ordinary reality, or to dance and have fun. The results were not necessarily what they expected. Bad trips were common, especially among novice users who were unprepared for the intensity of the experience or who took the drugs in an environment that was overstimulating or hostile. Even with the same individual, the perception of the "trip" could be markedly different. In the afterword to his book The Harvard Psychedelic Club, Don Lattin (2009) describes taking LSD with his girlfriend in Big Sur, and contrasts this very positive experience at that time with a subsequent very bad experience with the same girlfriend in a very different setting.
Drugs sold on the streets as psychedelics were often PCP or LSD adulterated with PCP, STP, (7) or methamphetamine. After effects such as flashbacks or prolonged psychosis were not uncommon, but the mainstream media focused on the more serious and dramatic, but less common events such as homicides or self-mutilations and deaths caused by people high on LSD who were delusional or exhibiting impaired judgment (see Editors of Time 1966a, b).
LSD, already made illegal in California in October of 1966, was eventually classified by Federal Regulation as a Schedule I drug: that is a drug with high abuse potential but no accepted medical use, the same category as marijuana and heroin, where it remains today. Classifying LSD and similar psychoactive drugs had the effect of curtailing legitimate medical research, but had no effect on its street availability, since almost all LSD was manufactured illicitly.
SAN FRANCISCO GENERAL
After completion of my rotation to Napa State Hospital, I was assigned to the emergency room at San Francisco General Hospital, the primary public treatment facility for the city and county of San Francisco. As a psychiatry resident, it was my job to evaluate the mental status of people who were possibly suicidal or psychotic and determine whether or not they should be admitted to the hospital. In addition to those brought by family or ambulance, police cars and vans arrived in a stream all day and night bringing people for psychiatric evaluation--people who had been detained because they were walking down the street naked or doing something that was life-threatening to themselves or possibly others. The police also brought prisoners from jail. Withdrawal seizures in jail from alcohol or barbiturate withdrawal were a common reason.
Duty shifts in the emergency room were a brutal 24 hours. Sleep deprived and exhausted, I went from one holding room to another, sometimes attempting to talk down a patient on a bad acid trip or to evaluate someone pulled from the Golden Gate Bridge. From police officers' points of view it was, "If he's high on drugs, he's ours; if he's schizophrenic, he's yours." If the person was suicidal or acutely psychotic--whatever I thought the cause might be--I admitted them to one of the four acute psychiatric wards.
After my emergency room rotation, I was assigned to one of the psychiatry wards, a 30-patient locked psychiatric ward across the street from the emergency room entrance. The psychiatrist in charge of the unit was a middle-aged woman, a well-trained psychiatrist who was on the clinical staff of the University of California San Francisco Medical School. One morning, I was informed by the head nurse that the psychiatrist-in-charge had been hospitalized and that it was not known when she would return. I was in charge.
Of the 30 patients a few were voluntary, many were on court hold for evaluation and a few were prisoners from the San Francisco jails. The prisoners were often severely disturbed, acutely psychotic or they had had one or more alcohol or barbiturate withdrawal seizures while in custody. If the prisoner was being held for murder or assault, a police officer was usually detailed to the ward.
It was known in 1968 that barbiturate withdrawal could result in seizures, psychosis, or death (Wikler 1968; Ewing & Bakewell 1967; Altman et al. 1965; Jaffe & Sharpless 1965). The accepted protocol of withdrawal from barbiturates at the time was to stabilize the patient on a mildly intoxicating dose of pentobarbital and then taper the pentobarbital over a period of about ten days. Sedative-hypnotic tolerance, a result of physical dependence, was sometimes assessed by administering a 200 mg "test" dose of intramuscular pentobarbital. Patients who were not physically dependent usually became mildly intoxicated, with slurred speech and ataxia following the test dose. Patients who didn't become intoxicated were presumed to be physically dependent and withdrawn slowly.
Inpatient Treatment of Sedative-Hypnotic Dependence
Many of the drug-dependent patients, particularly those from jail, didn't provide a very accurate history of their drug use and generally maneuvered to get as much withdrawal medication as possible. "Hey doc, I'm taking 30 reds a day." I figured that they were probably exaggerating, so that 20 secobarbital (100 mg) capsules per day would possibly be a reasonable starting dose. But even on that dose, some became acutely intoxicated the first or second day and some of those became belligerent or verbally abusive to the hospital staff or, foolishly, to the police officer who had been detailed to the ward. Police officers generally had little patience with patients' obnoxious or belligerent behaviors, particularly on the night shift when nursing staff was minimal. Some patients developed bruises after they arrived on the ward. "Fell down during the night," I was told by either the nurse or the police officer. Obviously my withdrawal treatment strategy wasn't working very well.
The director of the residency program told me that I should talk with David Smith, the new Chief of the Alcohol and Drug Abuse Screening Unit at San Francisco General. David's recommendation of phenobarbital for barbiturate withdrawal was straightforward deductive logic. The first premise was that a short-acting drug should be substituted for a long-acting one (thus methadone for heroin). The second premise was that intoxication is not necessary to prevent emergence of severe withdrawal signs and symptoms. It followed logically that substitution of phenobarbital, a long-acting barbiturate, for secobarbital, a short-acting one, at a sub-intoxicating dose was a reasonable treatment strategy.
Phenobarbital, it turned out, had additional benefits. It is less likely to produce behavioral disinhibition than pentobarbital should intoxication occur, and signs of intoxication--slurred speech, staggering gait, and sustained horizontal nystagmus--were easy to observe in a reasonably cooperative patient. Horizontal nystagmus is a flicking eye movement that occurs when looking to the extreme right or left. Many people to have a one or more beats of nystagmus on extreme gaze, but the movements normally cease. If someone is intoxicated on phenobarbital or other sedative-hypnotics, the eye movements persist. Horizontal nystagmus is the most reliable sign of sedative-hypnotic intoxication because it is easy to observe and impossible to feign. Also, phenobarbital, already widely used for treatment of seizure disorders, was familiar to most physicians, and because it was an anticonvulsant, likely to reduce or prevent barbiturate withdrawal seizures. David initially proposed that a phenobarbital sedative dose of 60 mg be substituted for each "hypnotic" dose (100 mg in the case of secobarbital or pentobarbital). After several patients became intoxicated with this equivalency, he revised the recommendation, 30 mg of phenobarbital for each 100 mg of short-acting barbiturate. This hypnotic dose to "sedative withdrawal equivalency" was the basis of tables that we published and have been widely incorporated in other's journal articles and textbooks. After a stabilization period of two days, the daily dose of phenobarbital was decreased 30 mg/day.
The nurses and the unit intern quickly learned how to observe horizontal nystagmus and the next barbiturate-dependent patient was administered phenobarbital. Although phenobarbital is very long acting, there seemed to me to be practical reasons to administer the phenobarbital in three doses per day, one dose on each nursing shift. That way the patient would be evaluated by a different nurse on each of the three shifts. Should nystagmus be present, nurses were directed not to administer the dose of phenobarbital. Should the patient become intoxicated, hopefully the intoxication would be detected by one of the staff. Also if a nurse inadvertently didn't administer one of the three doses, only a third of the daily dose would be missed. Knowing that they would probably get a medication dose on shift, patients were less prone to clamor for "more medication" to each new shift of nurses.
After changing to the new regimen, there were no withdrawal seizures or episodes of severe barbiturate intoxication. The patients didn't necessarily like phenobarbital, saying that it "wasn't working," which I interpreted as their missing feeling intoxicated.
The first publication describing our use of phenobarbital was a publication of the University of California Berkeley (Smith, Wesson & Lannon 1969). Later, a paper describing our clinical experience and detailing the inpatient protocol was published in the Journal of the American Medical Association (Smith & Wesson 1970) and a longer report appeared in the Archives of General Psychiatry (Smith & Wesson 1971).
OUTPATIENT TREATMENT AT HAFC
The articles cited above concerning treatment of barbiturate withdrawal all indicate that it should only be done in an inpatient setting since the consequences of improperly managed sedative-hypnotic withdrawal could be lethal, either due to overdose or uncontrolled barbiturate withdrawal. After opening of the drug treatment section of the Haight Ashbury Free Medical Clinic, it soon became apparent that there were not sufficient inpatient resources in the San Francisco area to treat all the sedative-hypnotic dependent patients who needed treatment. By 1968, benzodiazepines such as chlorodiazepoxide and diazepam were clinically available and much safer in an overdose situation than the short-acting barbiturates, but seemingly less effective at suppressing barbiturate withdrawal seizures. Also, benzodiazepines, particularly diazepam, were sought-after drugs by abusers and had street value. Phenobarbital, although more effective from a medical perspective, didn't gain favor among drug abusers and had little street value.
A drug treatment clinic section of the Haight-Ashbury Clinic located in another Victorian diagonally across Clayton Street from the medical clinic opened under the direction of Dr. George (Skip) Gay. An anesthesiologist by training and a hippie by temperament, Skip was completely at ease among the patients in the clinic. He had the clinic's pharmacist dispensing phenobarbital for treatment of sedative-hypnotic dependence, having the daily doses administered to patients in the clinic pharmacy. One afternoon in the waiting room of the drug detoxification clinic, a couple of patients were slouched on a sofa, eyes half-masted, tremulous, and twitchy. One gestured toward me, slurring his words, "Doc, I need more medication, can't you see that?" I asked Skip what was up with them, because they both looked like they could have a withdrawal seizure at any moment. He scoffed at me then smiled, "Don't they teach you anything in psychiatry? That's Stage I anesthesia, uncomfortable... that's why you pay big bucks to the anesthesiologists not to experience it, or if you do, not to remember it." Skip broke an impish grin and put a hand on my shoulder. The experiences with outpatient withdrawal were later published (Gay et al. 1971).
DISSEMINATION OF THE WITHDRAWAL PROTOCOL
David and I were very pleased with the clinical results of the phenobarbital withdrawal protocol. With a phenobarbital withdrawal equivalent of 30 milligrams for each 100 milligrams of short-acting sedative hypnotic the patient claimed to be using, sedative-hypnotic withdrawal proceeded smoothly without a single seizure or acute psychotic episode induced by withdrawal, and intoxication, if it occurred, was easily detected and did not result in behavioral management problems.
We wanted as many physicians as possible to be aware of the phenobarbital protocol because it appeared to be a substantial improvement over pentobarbital, which was most commonly used for treatment of barbiturate withdrawal at the time. In the early 1970s, before Google or the World Wide Web, nonacademic physicians usually obtained new information from conferences, colleagues or journals. The journals were in their specialty area. Among American physicians, the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine were the most widely read. Many physicians received JAMA as a membership benefit in the AMA. Psychiatrists were more likely to read Archives ofGeneral Psychiatry. In submitting a description of the phenobarbital protocol to JAMA and later a version to Archives ofGeneral Psychiatry (which included case examples), we achieved our intended goal of disseminating the protocol widely, as well as the unintended consequences of a plethora of bad Smith and Wesson jokes.
The publications also gave us visibility in Washington, DC. Staff for Senators Ted Kennedy and Birch Bayh were identifying witnesses for upcoming senate hearings on the abuse of barbiturates. They wanted witnesses who would talk about barbiturate's addictive potential, their abuse and dependence, and the difficulty patients had during withdrawal. When we told the staffers that kid took "reds" to party or go to a rock concert, some responded that what we were claiming was impossible because Seconal and Nembutal were sleeping pills and anyone taking them would fall asleep. By drawing an analogy with alcohol, we eventually convinced them that under the right circumstances, a sedative-hypnotic could appear to have stimulant properties. I testified at both Senator Kennedy and Senator Birch Bayh's (8) hearings in 1972.
From their viewpoint, I was a friendly witness, telling them the kind of "war stories" they wanted to hear. My testimony was followed by a representative of the American Medical Association, Dr. Henry Brill. Flanked on either side by an attorney, Dr. Brill made it abundantly clear that the AMA was opposed in principle to any federal government regulation of medicine or prescription drugs.
Later we chronicled the history of barbiturates' development, the discovery of their withdrawal syndrome, and their abuse and diversion in a short book, Barbiturates: Their Use, Misuse and Abuse (Wesson & Smith 1977).
ADDITIONAL OBSERVATIONS AT THE HAIGHT-ASHBURY FREE CLINIC
People with health insurance came to the free clinic because they were embarrassed to go to the regular physician or because they didn't want their insurance or employer to know that they were using drugs or that they had a sexually transmitted disease. Even in the clinic, they often registered under assumed names.
One night an attractive young woman--smartly dressed in financial-district attire--sat upright in the graffiti-decorated waiting room, in contrast to the other patients who slouched or sat on the floor. She anxiously glanced around at the other patients, her hands primly folded in her lap. The other patients looked back at her, somewhat in disbelief that she would be sitting in the clinic's waiting room. I ushered her and one of the female volunteers into an exam room and inquired about her reason for visiting. She pushed up the sleeve of her blouse revealing bruises, swelling, and needle marks at the bend of her left arm. Barbiturates had been injected into tissue next to a vein. Very irritating to tissue, barbiturates caused sterile abscesses, or, in some cases, an infected abscess requiring incision and drainage. Hers did not appear to be infected.
Some youth used barbiturates as an alternative to alcohol, which, except for cheap wine, was viewed as "establishment." One night a young couple, perhaps 14 and 15 years of age although presenting themselves as older, appeared in the waiting room with the complaint of "reds" written on the intake form. He was acutely intoxicated-with slurred speech, sustained horizontal nystagmus, and unsteady gait--although soft-spoken, polite and cooperative. Both were runaways from the Midwest and had been living in Haight-Ashbury for several months. Both came from families where the father was alcoholic, and they were determined not to end up "like him." He was using reds orally, every day. They had fights about the pills, she hid them and sometimes flushed them down the toilet. His reason for coming to the clinic was to get a physician to assure her that reds were not addicting like alcohol and to tell her to stop throwing away his pills. I was unable to comply with either of his requests.
WHAT WAS LEARNED
From a perspective of slightly more than 40 years, perilously close to the edge of living memory, those of us who remember the sixties are perhaps overly nostalgic in the way that old folks are prone to be, and to believe that we played more of a role than we might have. Nonetheless, it seems that there is an important history that should not be forgotten. Don Lattin (2009) has elegantly and poignantly written in The Harvard Psychedelic Club:
The sixties were such a divisive decade that, when we look back on it, we tend to forget that the "counterculture" was not just against everything. The antiwar movement was for peace. The civil rights and feminist movements were for equality. The environmental movement was not just against pollution; it was for a new way of seeing the interdependence of all living things.
"Do your own thing" as an operating principle for social groups has practical limitations. Someone has to fix the leaky water pipes or tend to clogged sewers, and otherwise do the unpleasant tasks that no one wants to do. Infrastructure requires maintenance, a point not adequately grasped by hippies or, for that matter, by many people today who protest paying to build and maintain the complicated infrastructure that provides clean water, electricity, waste disposal, police and fire services, education of the young, and paved streets and roadways.
Prohibition of commonly used drugs based on the dichotomy of "good drugs" and "bad drugs" results in ineffective and harmful drug policy. The war on drugs, which began in earnest during the sixties, unfortunately continues to the present. Although no longer called "war on drugs," it is still prosecuted with the same tactics, with increasingly real war consequences, particularly for people who live along the border between the US and Mexico. The justification for prohibition is couched in terms of a drug's potential dangers, but danger is relative, as related to the context and method of drug use as it is an inherent property of the drug. Using similar logic, one could imagine prohibiting automobiles because they are potentially dangerous if driven on the sidewalk at 100 miles an hour.
Criminalization of marijuana produced social problems in the sixties; it produces social problems now, and the people who formulate US drug control policy seem incapable of learning from past mistakes, so they doggedly pursue a failed policy of prohibition, seemingly incapable of realistically assessing the human and economic costs/benefits of putting people in jail for marijuana possession. Medical marijuana as a partial solution is an illogical response, not because marijuana may not have medical utility under certain circumstances for some people, but because there is no standardized product of known purity and THC content, which would be a reasonable minimal requirement of any medication. Smoked marijuana is certainly not completely safe (does anyone seriously believe that sucking smoke from burning weeds deep into your lungs is good for the lungs)? But in retrospect, even psychedelic drugs produced surprisingly few problems (e.g., bad trips, flashbacks, and sometimes life-threatening erratic behavior) considering the large number of people who took them in circumstances that would have been challenging for the most psychologically together individuals. Making LSD illegal promoted its use and effectively stopped the exploration of psychedelic drugs as therapeutic agents or as probes for consciousness and perception. Fortunately, some human studies have recently resumed with psychedelics and related compounds (Grof 2009).
The persistence abuse of methamphetamine--in its many incarnations of smoking, intravenous injection, and snorting--was not predicted from the experience in the Haight Ashbury in the late sixties. The devastating effects of high-dose intravenous methamphetamine to the user and to the community were obvious to the staff of the medical clinic, the researchers in the Haight and the drug users themselves. "Speed kills," the motto that largely replaced "better living through chemistry," didn't refer so much to methamphetamine's immediate lethal effects--barbiturates were much more likely to result in unintended death by overdose--but to the death of the human spirit and a slow rotting of teeth, rational thinking, and compassion for others. Research done by the San Francisco Amphetamine Research Project at the time (see Dr. Roger Smith's "The World of the Haight-Ashbury Speed Freak": 165) provided an important clue, which never reframed public awareness. Methamphetamine use isn't spread by a drug dealer lurking in alleyway near a school yard, but from friends, who "turn on" their friends. At least initially, intravenous methamphetamine injection is likely to occur in a social context. The infectious agent is the user.
The US continues to wage wars in places where our national interest and moral justification is debatable, but fortunately nothing on the scale of Vietnam. We have a volunteer army, there is no draft. No one would argue that civil rights and racial equality have been resolved, but few would argue that progress has not been made. The same cannot be said for wealth distribution, which progressively is skewed toward the super-rich corporations and individuals.
Whatever the theories underpinning community mental health, they turned out in practice to be largely an illusion. When federal funding declined, state and local communities were unable to sustain the effort. The outcome was that many patients were discharged from the state mental hospitals and sent to communities that do not have the mental health and residential resources to deal with them, an effect still evident today in large numbers of mentally ill homeless living on the streets.
The phenobarbital withdrawal technique developed in 1968 was for many years the accepted standard of care for sedative-hypnotic withdrawal. Its development was based on sound pharmacological principles, deductive logic, and clinical observation. The short-acting barbiturates have been largely replaced as sedatives and hypnotics by the benzodiazepines and newer sleeping medications that are similarly acting, although not chemically the same as benzodiazepines, and work at receptors in similar ways. The benzodiazepines and newer hypnotics, despite abuse, are much less likely to be fatal in the event of an overdose. Also, they are not injected, so they are significant improvement over barbiturates.
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Editors of Time. 1967b. Youth: The Hippies. Time July 7. Available at http://www.time.com/time/magazine/article/0,9171,899555-10,00. html?artId=899555?contType=article?chn=us
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(1.) The Benzedrine[R] inhaler contained methamphetamine, unlike its later replacement Benzedrix[R], which contained phenyl-propanolamine.
(2.) Flagyl[R] (Sanofi-Aventis) is the trade name of metronidazole a medication used for treatment of trichomoniasis and some other infections.
(3.) The version of this book consulted in preparation of this paper was Huxley, A. 2009. The Doors of Perception. New York: Harperperennial Modernclassics. a paperback edition that bundles Doors of Perception, Heaven and Hell (1956) and several of Huxley's essays.
(4.) The deferment was known as "the Berry Plan." A history of the Berry plan is available at http://jama.amaassn.org/content/175/1/57.full.pdf.
(5.) A facsimile compilation of all 12 issues with the addition of historical notes has been published in an beautiful oversized book edition (Cohn 1991). The pages in the book are numbered sequentially and do not conform to page numbering of the newspaper. Also see http://www. regentpress.net/oracle/index.html
(6.) See http://www.stanislavgrof.com.
(7.) STP is a street name for 2,5-dimethoxy-4-methylamphetamine, a long acting hallucinogen documented at the Haight-Ashbury Medical Clinic in November, 1967 (see Smith 1969b). STP was widely said to stand for Serenity, Tranquility and Peace, but Alexander and Ann Shulgin relate that it was also reported to stand for Super Terrific Psychedelic or Stop The Police. They claim that the term "STP" was actually taken from the initials of a motor oil additive, with which it was not related chemically (Shulgin & Shulgin 1991).
(8.) Birch Bayh, Senate Subcommittee Hearing on Juvenile Delinquency (December 15-16, 1972).
([dagger]) The author would like to thank Sarah Calhoun for reviewing successive drafts of this paper and providing many helpful comments.
Donald R. Wesson, M.D., Consultant, CNS Medications Development, Oakland, CA.
Please address correspondence and reprint requests to Donald R. Wesson; email: drwesson;comcast.net
TABLE 1 Chronology of Events 1965-1973 * Date Event 1962 Publication of Rachael Carson's (1962) Silent Spring about the detrimental environmental effects of pesticides launches the environmental movement. January 20, 1965 Lyndon Johnson served the remainder of John F. Kennedy's term following Kennedy's assassination on November 22, 1963. Johnson was reelected president and inaugurated January 20, 1965. January 12-14, 1966 Ken Kesey's TRIPS festival at the Longshoremen's Hall in San Francisco, one of the events popularizing the "hippie" movement. The Grateful Dead played. Bill Graham was involved in the organization of the event. March 26, 1966 Antiwar protests in New York, Washington, Chicago, Philadelphia, Boston and San Francisco. September, 1966 First issue of the San Francisco Oracle, the Love Pageant Rally issue. October 6, 1966 Lunatic Protest Demonstration: a "celebration" in opposition to California legislation making LSD illegal. January 2, 1967 Ronald Reagan inaugurated governor of California. January 14, 1967 Be-in, Golden Gate Park Polo Field, San Francisco. Timothy Leary encourages attendees to "turn on, tune in and drop out." February 8-10, 1967 American religious groups stage a nationwide "Fast for Peace." April 15, 1967 Antiwar demonstrations in New York and San Francisco. June 1967 A song, "San Francisco (Be sure to Wear Flowers in Your Hair) written by John Phillips of the Mommas and the Papas was released to promote the Monterey Pop Festival, performed by Scott McKenzie. June 7, 1967 Opening of Haight Ashbury Free Medical Clinic June 16-18, 1967 Monterey International Pop Music Festival. June 24, 1967 UCSF Medical Center Conference: Psychedelic Drugs and the Law. July 7, 1967 Hippies on the cover of Time with a feature article. October 6, 1967 Mock funeral staged in Haight-Ashbury: Death of the Hippies. October 21-23, 1967 Antiwar protestors march on Pentagon. November 27, 1967 Beatles release "Magical Mystery Tour" album. April 4, 1968 Rev. Dr. Martin Luther King, Jr. assassinated in Memphis, Tennessee. June 5, 1968 Robert Kennedy assassinated in Los Angeles. January 13, 1969 Beatles release "Yellow Submarine" album. January 20, 1969 Richard Nixon begins first term as president. July 15, 1969 Attorney General John Mitchell sends Congress the Nixon Administration's Bill for the "War on Drugs." It becomes the Comprehensive Drug Abuse Prevention and Control Act of 1970, which categorizes LSD Schedule I: high abuse potential but no medical use. May 18-19, 1969 Miami Pop Festival. August 15-18, 1969 Woodstock Festival. December 6-7,1969 Altamont Speedway Free Festival (Altamont is east of San Francisco). May 4, 1970 Kent State University massacre (four students killed, nine wounded by Ohio National Guardsmen during antiwar protest). October 27, 1970 President Nixon signs the Comprehensive Drug Abuse Prevention and Control Act of 1970. June 13, 1971 New York Times publishes the first installment of the Pentagon Papers. January 27, 1973 The draft is ended. March 27, 1973 End of US combat in Vietnam war. * This listing was compiled from a variety of sources.
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|Author:||Wesson, Donald R.|
|Publication:||Journal of Psychoactive Drugs|
|Date:||Jun 1, 2011|
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